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C] Appendix VI `'a' A . ; 0 7 ! 014 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://vvww.swrcb.ca.gov.) MONITORING SYSTEM CERTIFICATION ENVIRONMENTAL � , �-� r+ �n, °rhr��a For Use By All Jurisdictions Within the State of California t'EA'_ , ' `"' ° ' R ° ' ENT Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: CHEVRON 208118 N-4087-1-3 Bldg. No.: Site Address: 3355 E. HAMMER LANE@ HOLMAN RD Facility Contact Person: MANAGER City: STOCKTON Contact Phone No.: 209-477-3699 Make/Model of Monitoring System: Veeder Root TLS -350 B. Inventory of Equipment Tested/Certified (hark the tj re riate hnxac to indirata cnerifir eauinment inenected/serviced: Zip: 95212 Date of Testing/Servicing: 2/20/2014 Tank ID: TI - SUPREME Tank ID: r, In -Tank Gauging Probe. Model: MAG r— In -Tank Gauging Probe. Model: rV Annular Space or Vault Sensor. Model: 409 r Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: 208 r, Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: r Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: r Mechanical Line Leak Detector. Model: rV Electronic Line Leak Detector. Model: Veeder Root PLLD Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: FLAPPER Tank Overfill / High -Level Sensor. Model: Other(specify equipment a and model in Section E on Page 2). Other(specify equipment type and model in Section E on Pae 2 . Tank ID: T2 - REGULAR Tank ID: In -Tank Gauging Probe. Model: MAG r In -Tank Gauging Probe. Model: ry Annular Space or Vault Sensor. Model: 409 Annular Space or Vault Sensor. Model: ' Piping Sump / Trench Sensor(s). Model: 208 ( Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Veeder Root PLLD Electronic Line Leak Detector. Model: �` Tank Overfill / High -Level Sensor. Model: 208 Tank Overfill / High -Level Sensor. Model: I Other(specify equipment a and model in Section E on Pae 2). Other(specify equipment a and model in Section E on Pae 2). Dispenser 1/2 Dispenser 7/8 ID: ID: rvo Dispenser Containment Sensor(s). Model: 208 rV Dispenser Containment Sensor(s). Model: 208 r Shear Valve(s). rV Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s). Dispenser 3/4 Dispenser 9/10 ID: ID: r', Dispenser Containment Sensor(s). Model: 208 rV Dispenser Containment Sensor(s). Model: 208 r%_1 Shear Valve(s). r' Shear Valve(s). Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). Dispenser 5/6 Dispenser 11/12 ID: ID: Dispenser Containment Sensor(s). Model: 208 Dispenser Containment Sensor(s). Model: 208 r%_1' Shear Valve(s). rV Shear Valve(s). r Dispenser Containment Float(s) and Chain(s). r Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): r System set- up r Alarm history report Technician Name (print): Timothy Elebeck Certification No.: 835252 Testing Company Name: Tanknology Signature. License. No.: 743160 Class'A' Phone No.: (800) 800.4633 Testing Company Address: 11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing: 2/20/2014 Monitoring System Certification Page 1 of 3 12/07